MCC Med Surg
The nurse prepares a presentation about AIDS for a group of students. Which information is important for the nurse to inlcude?
Abstinence is the most effective preventative method for HIV related to sexual transmission
The nurse organizes care for the client who just had a carotid arteriogram. Which i...
Check the puncture or cut down site for bleeding and hematoma for...
The nurse cares for a client diagnosed with a spinal cord injury at the level of T-3. The client reports a pounding headache and nasal congestion. The nurse notes the client has profuse sweating from the forehead and piloerection. Which action does the nurse take first?
Checks the Foley catheter and tubing for kinks.
A client diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel during an automobile accident. The ED nurse knows the highest priority is given to which intervention?
Chest tube insertion.
The nurse cares for a client with increased intracranial pressure. Which activities contribute to...
Hand restraints Bowel Movement
The client has an internal radium implant for uterine cancer. Which client statement indicates an understanding of safety concerns?
It is okay for you to talk with me from the doorway."
A client diagnosed with cancer asks the nurse, "Why must I take so many medications?" Which...
Like bacteria, cancer cells can resist chemotherapy meds.
The nurse gives discharge instructions to a family of a client diagnosed with hepatic encephalopathy. The nurse determines further teaching is necessary if the family m...
Our parent should eat meat at every meal"
The nurse helps the client diagnosed with cancer make a plan for regaining weight that was lost during antineoplastic therapy. Which food should the nurse suggest to provide the highest protein and calorie intake?
Peanut butter and banana sandwich
A client with a history of kidney disease is reporting weakness and lethargy. The client's electrocardiogram shows sinus bradycardia with a prolonged PR interval. Which lab value does the nurse expect to find?
Potassium 8.5 mEq/L
The nurse provides care for a client diagnosed with heart failure. For which reason are the client's fluids restricted?
Stroke volume is impaired and cardiac output is decreased.
The home health care nurse visits a client diagnosed with chronic bronchitis. The nurse notes the client is weak and congested. It is most important for the nurse to make which statement?
Take 3 or 4 deep breaths, and as you exhale the last breath, cough 3 times.
A client was involved in a motorcycle accident and is diagnosed with a spinal cord injury and fracture of T12. Once the client is stabilized, the nurse plans for the client'...
The client will have wheelchair independence and possible ambulation with long leg braces and crutches.
A client is being prepared for peritoneal dialysis. Which nursing action is taken FIRST?
Warm the dialysate.
The nurse provides care for a client diagnosed with cancer receiving chemotherapy. The client shares with the nurse how upsetting losing the hair will be. Which statement by the nurse is best?
Your hair will begin to grow back when chemotherapy is over."
The nurse provides care for a client who just had a thoracic aneurysm repaired. Which intervention does the nurse carry out in the immediate postoperative period? Select all that apply.
a) Monitors the drainage from the chest/mediastinal tubes. b) Performs circulatory checks. c) Assesses nasogastric drainage. e) Prevents thrombophlebitis.
the client has a 3-chambered chest drainage system (Pleur-evac) in place to correct a hemothorax. which action should the nurse take when caring for this client?
assess the client's respiratory status frequently.
The nurse provides care for a client diagnosed with alcoholic cirrhosis. The client is at high risk to develop which complication?
epitaxis
the nurse cares for an adolescent client after a skateboard accident that resulted in a brief episode of unconsciousness. the client's scalp and facial lacerations were treated and dressed in the emergency department. which nursing measure is the hig...
frequently asses the client using the Glasgow coma scale
A client is admitted with a diagnosis of acute kidney injury. The nurse understands which explanation is the MOST accurate description of the client's condition?
sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage.
The client had a transurethral resection of the prostate (TURP). On the third postoperative day,...
temporary urinary incontinence is not unusual following catheter re...
The nurse provides care for a client admitted with diagnosis of acute pancreatitis. The nurse administers morphine sulfate intravenously for reports of pain. Which clie...
the client sleeps for one hour
the nurse cares for the client diagnosed with breast cancer after a positive breast biopsy. the client refuses to believe the diagnosis and says, "I do not have the C-disease." when planning nursing interventions, which is an initial short-term goal?
the client will say the word "cancer"
the nurse provides care for a client after a coronary artery bypass graft. which observation during the postop period most concerns the nurse
the heavy chest tube drainage suddenly stops
The nurse provides care for a client recuperating from a splenectomy. Which intervention does the nurse implement in the immediate postoperative period?
the need to breathe deeply frequently
The nurse teaches a class about cardioversion. The nursing student asks, "how doe...
the position of the synchronizer switch on the defibrillator is differe...
the nurse assesses the client diagnosed with a head injury and notes the client's arms are stiffly extended, abducted, and hyperpronated. the client's legs are hyperextended with plantar flexion of the foot. which is the best way for the nurse to interpret the client's position?
this is decerebrate posturing and results from disruption of motor fibers in the midbrain and brainstem.
the nurse hears crackles in all lung fields while assessing a client's respiratory status. which condition causes crackles?
underlying inflammation or congestion
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents:
ventricular depolarization
A client has a family history of pancreatic cancer and wants to know how to recognize the disease in the early stages. The nurse instructs the client about whic...
weight loss and jaundice